Abstract
Osteoid osteoma, osteoblastoma, and haemangioma should be included in the differential diagnosis of any young patient with pain in the back or the neck, painful scoliosis, or radicular or referred-type pain into the lower limb or the shoulder. Osteoid osteoma and haemangioma may occur in the same cervical spine and both have a significant importance in the prognosis, management and possible complications. Early diagnosis with a bone scan and computed tomography scan, leading to prompt treatment, decreases the average duration of symptoms by two thirds. Early diagnosis and treatment of symptomatic vertebral haemangiomas is essential to prevent permanent and irreversible neurologic deficit.
BACKGROUND
Osteoid osteomas and osteoblastomas are benign tumours that, when they occur in the spine, can produce severe pain and secondary permanent scoliosis. Vertebral haemangioma is the most commonly encountered tumour of the vertebral column. The haemangiomas may involve any portion of the spinal column, including the sacrum, but occur most often in the thoracic spine followed by the lumbar spine deformity. It is rather unusual to see osteoid osteoma and haemangioma in the same cervical spine. We present the case of a 25-year-old man with osteoid osteoma and haemangioma in the same cervical spine, and discuss the interesting facts, rarity, and surgical management, complications and prognosis.
CASE PRESENTATION
A 25-year-old man came to our spine outpatient department with neck pain for 3 months. He was a basketball player. Pain was a dull aching in the neck with radiation to both shoulders. Neck pain was present soon after playing and before going to sleep. He consulted a local practitioner and got relief by taking 1 g of paracetamol at night. Clinical examination revealed mild tenderness in the fifth cervical vertebra. Nerve roots signs were not present. Neurology was intact.
INVESTIGATIONS
Radiographs (fig 1) of the cervical spine were normal. Computed tomography (CT) scans (fig 2) showed sclerosis of the right pedicle and lamina surrounding a lytic lesion with a central calcific nidus. Magnetic resonance imaging (MRI) with T1 weighting (fig 3) demonstrated diffuse low signal intensity within the pedicle and lamina of the C5 vertebra on the right side in the parasagittal sections, with corresponding high signal on T2 weighting. No abnormal soft tissue component was seen. Osteoid osteoma of the fifth cervical vertebra with associated haemangioma was confirmed.
Figure 1. Radiographic evaluation of cervical spine was essentially normal (panels A, B).
Figure 2. Computed tomography demonstrated sclerosis of the right pedicle and lamina surrounding a lytic lesion with central calcific nidus (panels A–C).
Figure 3. Magnetic resonance imaging with T1 weighting demonstrated diffuse low signal intensity within the pedicle and lamina of C5 vertebra on the right side in the parasagittal sections, with corresponding high signal on T2 weighting (panels A–C).
No abnormal soft tissue component was seen.
TREATMENT
Wide excision of the osteoid osteoma was done. It was decided to treat the haemangioma conservatively considering the nature of the lesion and its benign asymptomatic presentation.
OUTCOME AND FOLLOW-UP
The patient made a symptomatic recovery within 6 months. He is now free of symptoms at the end of 4 years.
DISCUSSION
Described by Jaffe in 1935, osteoid osteoma is a benign skeletal neoplasm consisting of a highly vascularised nidus of connective tissue surrounded by sclerotic bone. The nidus is usually <15 mm and when larger is classified as an osteoblastoma. Osteoid osteoma comprises 10% of all benign bone tumours and only 1% of all spinal tumors.1 Patients with osteoid osteoma are usually younger and rarely present after 30 years of age. Local pain and tenderness is the presenting symptom in over 95% of cases. Scoliosis and torticollis may be presenting features in thoracolumbar and cervical spine regions. Lesions in the cervical spine can produce radicular-type symptoms in the shoulders and arms,2–4 but the results of the neurological examination are usually normal. The complex spinal anatomy may make osteoid osteoma almost impossible to visualise on conventional radiography.4–7 Radionuclide bone scanning is more reliable than conventional radiography. The intense osteoblastic activity within the nidus results in a focal uptake surrounded by a decreased uptake owing to the sclerotic bone creating the “double density” sign that is typical.2 On MRI, osteoid osteoma demonstrates a heterogeneous appearance. The calcification within the nidus and surrounding bony sclerosis is of low signal intensity on short TR and long TR images.3,7 Bone scanning is now accepted as being the most accurate means of localising the tumour. CT has been shown to be very helpful for precisely defining the location of the tumour and the extent of osseous involvement.7 Surgical excision or curettage is the treatment of choice. In recent years, several CT guided percutaneous techniques, such as CT guided percutaneous radiofrequency ablation, have been used to achieve removal or destruction of the nidus, and the results seem to be very good and free of complications.6
Vertebral haemangioma is a benign vascular lesion of bone, usually of dysembryogenetic origin or a hamartomatous lesion.8–11 It can be cavernous, capillary or a mixed type. The symptomatic ones may have only pain (54%) or may be associated with variable neurologic symptomatology (45%). The haemangiomas may involve any portion of the spinal column, including the sacrum, but occur most often in the thoracic spine followed by the lumbar spine. The symptoms probably resemble a metastatic lesion of the spinal column, perhaps with the exception that the metastatic lesions8–12 progress more rapidly than those resulting from the haemangioma. The treatment modalities include surgical decompression, endovascular embolisation, radiotherapy, injection of absolute alcohol or methyl methacrylate into the vertebral body, or any combination of these. The non-surgical modalities are used due to the highly vascular nature of the tumour, with the threat of mortality due to exsanguination during surgery and the difficulty in approaching and totally excising the tumour with its associated morbidity.12
Lewis and Reilly studied a series of patients who initially had been thought to have a sports related knee injury, but ultimately were diagnosed as having a primary bone or soft tissue tumour or a tumour-like condition involving the knee.13,14 Schwartz and Limbird reported on 13 patients who had had arthroscopy before they eventually were diagnosed as having a tumour. A delay in diagnosis allowing tumor progression or an alteration of previously uncontaminated tumour margins may change the tumour stage and substantially affect the type of surgical techniques that must be used, as well as the prognosis.15 The clinical presentation of a musculoskeletal tumor may mimic that of a sports related injury. Proper clinical examination, radiological investigations and a high suspicion for combination of various tumors will be helpful in earlier diagnosis and management of tumours. Our patient who was a young adult had symptomatic neck pain which was relieved by non-steroidal anti-inflammatory drugs. Radiology showed presence of both osteoid osteoma and haemangioma. The literature on haemangioma and osteoid osteoma is vast and refers, not specifically, to every vertebra in the spine. The fact that haemangioma and osteoid osteoma occurring in a patient has not been extensively described, does contribute a base for our observation.
LEARNING POINTS
Osteoid osteoma and haemangioma may occur in the same cervical spine of which both have a significant importance in the prognosis, management and possible complications.
Osteoid osteoma, osteoblastoma and haemangioma should be included in the differential diagnosis of any young patient with pain in the back or the neck, painful scoliosis, or radicular or referred-type pain into the lower limb or the shoulder.
Because of the complex anatomy of the vertebrae the possibility of scintigraphy and computed tomography combined is a better option than conventional radiography for evaluating lesion location and analysing bone destruction and condensation.
Proper clinical examination, radiological investigations and a high suspicion for combination of various tumours will be helpful in earlier diagnosis and management of tumours.
Footnotes
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication
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